Cluster headache (CH) is a type of primary headache that mostly affects adult men. Patients present with recurrent, fifteen minute up to three hour attacks of agonizing, strictly unilateral headaches in the periorbital and forehead region (areas innervated by the trigeminal nerve). These attacks are associated with ipsilateral symptoms of increased cranial autonomic activity, e.g., lacrimation, conjunctival injection, rhinorrhea, or partial Horner syndrome. Cluster headaches tend to occur in episodic patterns (“cluster bouts”) followed by months of remission, but are considered chronic if remission between bouts lasts less than one month. Diagnosis is based on the patient's history, in particular on the exact description and timing of the headaches. Acute episodes are treated with 100% oxygen or triptans, while verapamil is used for preventative treatment.
Epidemiological data refers to the US, unless otherwise specified.
- Not entirely understood
- Risk factor: tobacco use
- Possible triggers: alcohol, histamine, seasonal fluctuations
- Agonizing pain
- Strictly unilateral, periorbital, and/or temporal
Short, recurring attacks; that usually occur in a cyclical pattern (“clusters”)
- May become chronic (less common), with interruptions of less than one month between cluster bouts
- Attacks often wake patients up during sleep.
- Ipsilateral autonomic symptoms
- Restlessness and agitation
- Based on patient history and physical examination
- Rule out any suspected underlying disease
- See article on “” for more information regarding differential diagnoses.
- Clinical features
- Treatment: no established treatment for acute attacks
- Prevention: indomethacin
Short-lasting unilateral neuralgiform headache attacks
- Definition: a form of trigeminal autonomic cephalgia characterized by unilateral throbbing pain and autonomic symptoms (i.e., conjunctival injection and/or tearing)
- Unilateral throbbing, piercing, and/or burning head pain with temporal, orbital, or supraorbital distribution
- Attacks are frequent
- At least 1 per day
- Last between 1 second and 10 minutes as single stabs, a series of stabs, or in a saw-tooth pattern
- At least one cranial autonomic symptom is usually present
- Attacks can be triggered without a refractory period
- Diagnosis: mainly clinical following a history of atleast 20 attacks; CT or MRI may be used to rule out other causes (e.g., tumor)
- Treatment: no abortive treatment
The differential diagnoses listed here are not exhaustive.
- Consider obtaining an MRI of the brain with and without contrast to rule out secondary causes in patients with new diagnosis of cluster headache. 
- Consult neurology.
- Start abortive therapy. 
- Start prophylactic therapy
- Consider admission to neurologic service for patients with their first episode of cluster headache, suicidal ideation, or refractory pain.
Apply nasal sprays in the nostril that is not affected by congestion to improve absorption (except lidocaine, which acts locally).
Ergotamines and triptans should not be taken within 24 hours of one another because of the risk of coronary artery spasms.